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Response by Directors of WOOMB International Ltd to: billingsmentor: Adapting natural family planning to information technology and relieving the t user of unnecessary tasks Authors: Audrey D Smith

supportt and involvement in billingsmentor, following the publication of the above paper which seeks to compare two online systems purporting to offer the Billings Ovulation Method : one used by

Drs John and Evelyn Billings devolved to WOOMB International Ltd the authorityy of ensuring that the authenticity of the Billings Ovulation Method was maintained.

1 Response by Directors of WOOMB International Ltd to: billingsmentor: Adapting natural family planning to information technology and relieving the t user of unnecessary tasks Authors: Audrey D Smith and John L Smith The Linacre Quarterly 81 (3) 2014, The Directors of WOOMB International Ltd set out thesee responses to t questions addressed to t us asking for clarification regardingg our supportt and involvement in billingsmentor, following the publication of the above paper which seeks to compare two online systems purporting to offer the Billings Ovulation Method : one used by couples with the guidance of o a teacher,, the other an automated guidance and interpretation system provided by programmed algorithms. Drs John and Evelyn Billings devolved to WOOMB International Ltd the authorityy of ensuring that the authenticity of the Billings Ovulation Method was maintained. The Directors of WOOMB International Ltd will respond to those points raised in this paper which directly relate to the Billings Ovulation Method, its teaching service and its Rules. The hypothesis that billingsmentor can be used with the Billings Method will also be discussed. We emphasise it is not our intention to t be disparaging of John and Audrey Smith, billingsmentor and any trial or o experiment of billingsmentor but merely to highlight the different approaches of the two methods, Billings Ovulation Method and billingsmentor. The terms Billings Ovulation Method or Billings Method are used in this document to refer to the same Method. What is the Billings Ovulation Method The Billings Ovulation Method is a scientifically validated method of natural family planning which embodies the following key elements: each woman is an individual with her own unique patterns of o fertility andd infertility the understanding of patterns of fertility and infertility is essential knowledge to which every woman in the world is entitledd the method is easy to understand, simple to use, reliable andd effective a woman is asked to make and record daily observations, using her own words, of vulval sensation and any visuall appearancee of discharge the time of ovulation is identified i emphasis is therefore removed from menstruation as the key indicator of fertility accredited teachers of the Billings Ovulation Method assist couples to understand and attain autonomy in the managemen t of their combined fertility there are only 4 Rules off the Billings Ovulation Method designed to assist the couple to achieve or postpone pregnancy these 4 Rules apply to all stages of reproductive life this knowledge is disseminated through face to face clinical appointmenta ts, telephone counselling, approved on line teaching and recording systems, authenticc literature and

2 training programs using WOOMB approved curricula. The recommendation that a couple c seeks individual counselling is always emphasised. Fertility Pinpoint is the official online charting system specifically developed in conjunction with OMR& RCA Ltd and WOOMB International Ltd. In teaching of the Billings Ovulation Method, the woman is taught to t recognise both infertility and fertility and with the assistance of the teacher in the learning stages,, gains confidence in making decisions, thereby gaining autonomy to use the Billings Ovulation Method effectively throughout reproductive life. The teacher must be a good listener to assist her too interpret her patterns of fertility and infertility. The Drs Billings were insistent that a woman should s be encouraged to use her own words to describe her signss and symptoms as they were aware of, and sensitive to, differences in culture and language. For women of other languages, a prescribed list of English words from which a woman has to choose may not give the most appropriate words, especially when translated. Pre ovulatory infertility is identified by an unchanging pattern of sensation and/or discharge recognised by each woman in the normal course of her day and reflecting low ovarian hormone levels. At this time there is no cervical mucus present to assist spermm transport and survival and couple infertility is identified. Each woman has her own unique pattern of infertility or Basic Infertile Pattern (BIP). Any change from her BIP indicates potential fertility. A user of the e authentic Billings Ovulation Method is taught that a subtle change in sensation or appearance of the discharge can identify the beginning of the fertile phase. Whenever fertility is suppressed and ovulation is delayedd either during the stages of the Continuum (Brown 2011), or due to underlying pathology, a combined BIP can be b identified.. When regular cycles return, the woman is in a new reproductive life stage and will revert to one BIP. The Three Early Day Rules apply to this pre ovulatory phase of the cycle and cover all possible eventualities. The fertile phase is identified as a changing, developing pattern of variable length, leading to a slippery sensation. As demonstrated by Professor James B Brown, this changing, developing pattern is typically 5 6 days reflecting the rise of oestrogen and cervical response. This phase may be shorter or, in some cases, longer. A definite change to no longer slippery defines the Peak as the last day of slippery sensation. The significance of the rise in progesterone and the activationn of the Pockets of Shaw clearly identify the reason for the change following the Peak day and the confidence with which a woman can identify her Peak. Theree is only one Peak in a cycle. The Billings Ovulation Method is based on the scientific evidence that the length of the luteal phase is days from ovulation not Peak. The criteria for identification of Peak are clearly defined and the Peak is identified at the timee on its merits, not by the length of the luteal phase, which may or may not identify the fertility of the cycle. The Billings Ovulation O Method recognises ovulation occurring in a cycle when a Peak has been identified and, for f those seeking pregnancy also identifies optimum couple fertility. Couple fertility for each cycle finishes at the end of the third day following the identification of Peak and infertility continues until thee commencement of the next cycle.

3 However if Peak has not been identified, thiss does not necessarily indicate that ovulation hass not occurred but rather that it is nott obvious in the chart. In such a case, the couple continues to use the Early Day Rules, thereby empowering them to apply the correct Rules in their fertility management. The Billings Ovulation Method or Billings Method teaches the couple to recognise their patterns of fertility and infertility so that they can apply the 4 Rules. This teaching has nott changed: in the 1979 edition of Atlas of the Ovulation Method by Evelyn L Billings, John J Billings and Maurice Cataranich, the role of the cervixx in controlling fertility and the hormonal correlation between the woman s observations and ovarian hormones was described. The Method has been extensively trialled byy WHO and others and the trials reported in refereed journals. Discussion on the Linacre Quarterly published paper on billingsmentor billingsmentor: Adapting natural family planning to information technology and relieving the user of unnecessary tasks Abstractt p219. billingsmentor is i an automated Web based service for f the Billings Method of natural family planning The title of this paper states thatt informationn technology can be used to relieve the user of unnecessary tasks. The authors empathize with the viewpoint expressed in a paper, published in 1984, that users found the Billings Ovulationn Method too complicated too difficult to apply too many rules to follow and too many qualifications to remember. They T state that an automated system can simplify and improve use of thee Billings Method by removing the shortcomings. They further state that meta rules were designed to comprise the knowledge that must be acquired in order to apply the four rules of the Billings Ovulation Method. Meta rules developed for billingsmentor (p222) A. The length of the fertile phase (beginning with the changee described inn rule 3) depends on mucus being present, typically for two or three days but it may be longer. The lastt day that the woman senses slipperiness or lubrication at the vulvaa is the Peak. As demonstrated by Professor James B Brown, this changing, c developing pattern is typicallyy 5 6 days reflecting the rise r of oestrogen and cervical response. B. Normal luteal phases have a maximum length of 16 days followed by menstrual bleeding. Rule 4 above applies during the luteal phase. If bleeding doess not start by day 17 past the Peak the application of rule 4 must cease and rules 2 and 3 should be applied until another Peak is identified. (Rule 4 refers to Peak Rule) C. If a wet or slippery sensation s occurs during the first three days after a Peak has been identified then the counting of days as specified in rule 4 should cease and rules 2 and 3 should be applied until another Peakk is identified.

4 The criteria for identificationn of Peak are not detailed in this published paper. These instructions are not part of Billings Ovulationn Method teaching. D. If a woman is having regular cycles of normal length (maximum of 355 days) and she s experiences a day or days following menstruation when herr symptoms are of no sensation and no discharge (nothing felt/nothing seen) then this is her h BIP (called a dry BIP). E. If a woman is having regular cycles of normal length andd she does not have a dry BIP, she may have a non dry BIP. Theree is some sensation and/ /or some discharge in an unchanging pattern over the days following menstruation. This T pattern should be verified over three usually consecutive cycles before it is applied in rules r 2 and 3. These statements accord with existing Billings Ovulation Method teaching. There is only one BIP in each of these circumstances and each woman learns to identify her own BIP. F. If a woman is in a time t of infertility following the birth of a baby or following cessation of hormonal medication, or she is having long cycles, there may be a combination of symptomss that constitute a BIP instead of a dry or simple non dry BIP. The combined BIP is identified as an unchanging pattern which is a combination of symptoms nott leading to a wet or slippery sensation. The BIP is an unchanging pattern indicating constantt hormone levels and is identified by its unchanging nature, whatever the description. Whenever fertilityy is suppressed and ovulation is delayed either during all stagess of the Continuum (Brown 2011), or r due to underlying pathology, a combined BIP can be identified. G. When fertility returns (a Peak is observed) after a time of infertilityy the current BIP is no longer applicable and a new BIPP must be evaluated according to meta rules D and E. This accords with existing Billings Ovulation Method teaching. return the woman is in a new reproductive life stage and will revert to t one BIP. When regular cycles There are obvious differences between some of the rules devised by b Smiths and authentic Billings Ovulation Method Rules. To remove the shortcomings identified by their meta rules, the authors have simplified what they describe as the Billings Method. The stated two main functions of billingsmentor (p222) are to instruct the client to generate proper descriptions of her fertility symptoms (using the prescribed descriptors) and to interpret i thee symptoms efficiently according to the Billings Method and to communicate the results to the client. billingsmentor instructs the userss in a course of action. The Billings Ovulation Method or Billings Method teaches coupless to recognise their own unique patterns of fertility and infertility so that they can apply the 4 Rules which are based on clear, simple and verified knowledge, underpinned by an understanding of the roles and functions of the cervix in response to ovarian hormones.

5 Development of billingsmentor. The Smiths had worked with WOOMB International Ltd to develop the original internet teaching system from which the historical data of thee 54 studentss was extracted, however we emphasise that WOOMB International Ltd has had no ongoing involvement with billingsmentor. Reconstructed charts were used to emulate the experience which, the authors state, would have been attained if the women had used billingsmentor rather than thee earlier on line Web based system developed by the authors in The suggested efficiency of o the new directed system, billingsmentor, is then contrasted with the results they obtained under their web based teaching system. The registrations and histories of 54 women who had 300 days of charted record, (not necessarily consecutive days) were selected for retrieval and comparison and this data, including the charting data, was entered into billingsmentor. Thesee particular records camee from women who had used the on line teaching system during the period 2006 to 2010 and all these womenn had the assistance of accredited Billings Ovulation Method teachers throughout this period. Group A Group B Group C The described aim was to emulate the actions each client would have taken under the guidance of billingsmentor and compare these results with the actions taken under the web based charting service. The women selected were categorised into 3 groups. No recent fertility history events (not breastfeeding or recent use of hormonal contraception): 19 women ( 35%); Breastfeeding mothers: 21 women (39%); Recently ceased contraceptive medication: 14 women (26%). The authors state that while thiss may not be representative of a wider population of healthy fertile women it did provide a rigorous test of billingsmentor. (P235) Descriptions in the Teacher/Student records. The reconstructed comparative chart for 60 daily records for a particular student, (Figure 3) p.226 detail how a woman s words have been changed to fit standardised descriptions. To develop the program algorithms the woman s descriptions were standardised and 5 descriptors were entered: sensation, quantity, blood, colour and fluidity. billingsmentor requires 1 descriptor for sensation and 4 for the visual appearance, using set words. On p224, Smiths write w In their teaching document (Billings and Billings, 1997) Drs John and Evelyn Billings stated that each e woman is an individual and will describe her own mucus patterns in her own way but the Smiths express their opinion that this should not be taken as proscribing a limited vocabulary for describing the fertility symptoms in a discipline. In table 1 on p223, details are given of the prescribed vocabulary for billingsmentor, listing indicator characteristic and key discriminatory words. The mapping used involved the assigning of particular descriptions with a pre ordainedd word: e.g. p226, the colours of white cloudy and yellow were

6 mapped to opaque. If the description of fluidity was omitted, then it was described as thick if the colour was opaque, and thin (fluid)) if the colour was clear and vice versa if the description of colour was omitted. A number of key descriptors aree mapped together. The women in this investigation have had noo involvement in the standardised choices offered by billingsmentor. The Smiths indicate that they measured the performance of billingsmentor against the teaching service by identifying the number of Peaks recognised correctly and the number of days correctly classified as belonging to the Basic Infertile Pattern (BIP) or the luteal phase. Thee criteria used by billingsmentor to identify a Peak or to establish a BIP is not detailed in this paper. It is difficult therefore, to discusss the results that have been quoted. The identification of Peak and BIP following Billings Ovulation Method guidelines, have been validated by more than 850,000 hormonal assays conducted by Professor James Brown through all stages of reproductive life. Some other points of difference Method of recording a day with seminal fluid Length of luteal phase exceeded 16 days no ovulation Identification of a Billings Peak 1 Method of recording a day with seminal fluid Table 1: The vocabulary for billingsmentor indicates that the womann may choose only seminal fluid under quantity. The Billings Ovulation Method requires a woman w to record her observations of sensation and visual discharge every day, including days d of seminal fluid. She is discouraged from writing only seminal fluid on her chart, as its presence may mask the subtle change to fertility. If the woman was sure it was only seminal fluid there wouldd be no valid reason for Early Day Rule 2. Dr Evelyn Billings always stated that the rules mean what they say. Under Discussion p234, the authors state the same Billings Methodd sticker/symbol is used to t denote a wait day after intercourse (rule 2) and a possibly fertile dayy (rule 3), whereas there is a clear distinction in the height of the bar chart. The Billings Ovulation Method user applies the same sticker/symbol for any change from the BIP, including the presence of seminal fluid, as this may be obscuring the beginning of the mucus symptomm and potential fertility. Couples using the Billings Ovulation Method are taught never to make assumptions but to chart always what is experienced. 2 Length of Luteal Phase. Length exceeded 16 days no ovulation Table 2 has a category for Luteall Phases as Length exceeded 16 days no ovulation. If bleeding does not occur within 16 days then either there is a pregnancy or there was no

7 ovulation at the time of the suggested Peak (only a rise in the level of the oestrogen hormone) or else there was a fault in the maturation of the follicle. The studies conducted by Professor Brown on ovarian activity and thee Billings Ovulation Method proved the correlation between the woman s Billings Ovulation Method chart and showed that the variants in ovarian activity were identified accurately in the charting. The Billings Ovulation Method chart would not identify a Peak for f an anovulatory event. Without ovulation, there is no luteal phase. A user of the Billings Ovulation Method would not identify a Peak if the criteria are not present. 3. Identification of a Billings Peak The authors quote, Brown (2010, 2011) noted the correlation between ovulatory and anovulatory events at the Peak and associated subsequent bleeding. (P227) Types of ovarian activity in women and their significance: the continuum (a reinterpretation off early findings) Brown Human Reproduction Update. In the above paper, Professor James Brown life work on the Continuum of ovariann activity from menarche to menopause is detailed. This paper refers to oestrogens peaks and bleeding patterns following both ovulatory and anovulatory events. Brown also discusss cycles of ovarian activity both ovulatory and anovulatory, whereas Billings cycles are referred to as ovulatory menstrual cycles. Professor Brown s studies identified an oestrogen peak which can occur without a subsequent ovulation and can be followed by further oestrogen peaks, the last off which may result in ovulation and possibly a fertilee cycle. It is only for this latter peak that the Billings Ovulationn Method user would identify a Billings Peak, based on the criteria for Peak and thenn apply the Peak Rule. This explains the long discussions in this paper regarding the recognition of Peak Day, disputed Peaks or charts with several Peaks marked. This is not a featuree of Billings Ovulation O Method charts. The use of the term completed ovulation (page 229) is not found inn the published writings of Drs John and Evelyn Billings or Professor James Brown. On p225 the authors state thatt in 2012 there was a change to the guidelines g for recognisingg a Peak. This statement referred to a reiteration of the rationale behind the criteria for identifying the Peak day throughh an understanding of the beginning of the progesterone rise as explained by Professor James Brown and thee subsequent function off the Pocketss of Shaw as explained by Professor Erik Odeblad. There was no change to the authentic teaching as described by Drs John and Evelyn Billings in their published literature. These scientific understandings and the rationale behind the 4 Rules may not have been well understood when the Bettss article was published in 1984 but with improved trainingg and teaching techniques, they havee certainly been taught and explained by all accredited teachers of the Billings Ovulation Method.

8 Summary The Smiths state The main difference is that in the traditional teacher/student environment, the student must first interpret and encode her fertility by choosing a sticker or symbol for each day. billingsmentor interprets and encodes fertility on behalf of the client by analysing the sequence of symptoms and then generating a chart according to the rules and meta rules. (P234) The Billings Ovulation Method respects thee individuality of each woman, allowing her to identify her unique patterns of fertility and infertilityy and empowering the couple to make joint decisions regarding regulation of their fertility. After the initial learning stage, through an understanding of the woman s unique patterns, the couple become autonomous and can apply this information throughout all phases of reproductive life, only seeking further assistance if required. It allows the couple to attain stewardship of their t own fertility. The Rules of the Billings Ovulation Method,, the criteria for identifying Peak andd therefore ovulation, and the identification of a BIP are different from that described in the published paper. The Billings Ovulation Method is an effective and reliable natural method m of fertility regulation, validated by sciencee and is simply taught andd applied. Kerry Bourke, Joan Clements, Directors WOOMB International Ltd. 22 January 2015 Marian Corkill, Marie Marshell

9 References Betts, K The Billings Method of family planning: An assessment. Studies in Family Planning 15: Billings, E., and Westmore, A The Billings Method: Using the body s natural n signal of fertility to achieve or avoid pregnancy. Australia: Penguin Books: first published in 1980, new edition e Billings, E., Billings, J., Teaching the Billings Ovulation Method Part 2: variations of the cycle and reproductive health. Ovulation Method Research and Reference Centre of Australia Billings, E., Billings J., Catarinich, M Billings Atlas of the Ovulation Method: the mucus pattern of fertility and infertility. Ovulation Method Research and Reference Centre of Australia. Brown, J..B Types of ovarian activity a in women and their significance: The continuum (a reinterpretation of early findings). Human Reproduction Update 17: Corkill, M., Marshell, M. Natural Fertility Regulation: the Billings Ovulation Method. M Australian Doctor, How to Treat 19 December, 2008 Odeblad, E The discovery of the t different types of cervical mucus andd the Billings Ovulation Method. Bulletin of the Ovulation Method Research and Reference Centre of Australia 21(3): Odeblad, E Cervical mucus and their functions. The Irish College of Physicians and Surgeons 26: World Health Organisation Task Force on Methods for the Determination of the Fertile Period, A prospective multicentre trial of the Ovulation Method of natural family planning. 1. The teaching phase Fertility and Sterility 1981, 36, The effectiveness phase, Fertility and Sterility , 591 8

MORE THAN FERTILITY SAFEGUARDING YOUR REPRODUCTIVE HEALTH WITH THE BILLINGS OVULATION METHOD

MORE THAN FERTILITY SAFEGUARDING YOUR REPRODUCTIVE HEALTH WITH THE BILLINGS OVULATION METHOD 1 Introduction If you have heard of the Billings Ovulation Method, you probably associate it with teaching women